What do you think about water flossers?

What do you think about water flossers? Are they better than conventional flossing?

Water Flosser is an irrigation device which flushes out food particles, bacteria and plaque from under the gums and interdentally through a steady stream of water. This device can substitute flossing, as the water jet serves the same purpose of the floss.

To evaluate its effectiveness, we should look at the outcomes of using it, probably in place of floss, on the plaque scores (tartar attached to the tooth), pocket depths (pockets between gum and tooth), clinical attachment levels (levels of gum around tooth), gingival inflammatory markers (redness/soreness molecular indicators), tissue changes (redness/soreness of gums), and bone levels (level of bone around tooth, holding it).

Apart from these, patient compliance and ergonomics are also very important factors. A patient-centered quality of life (QoL) survey could throw more light on how well it is accepted by the patients and possibly, if it is making it easier for them to take care of themselves. Adding to the picture, or rather completing the picture, an incidence of any adverse events reported, if any, in the literature with adequate recommendations of using the device should be taken into account as well.

With all these questions, I searched for the evidence:

Histological Inflammation of tissue (Redness/Soreness of gums): In a split mouth-randomized clinical trial, it was found on histological examination of excised tissue from periodontal pockets between 3 mm and 6 mm that water flossing showed fewer inflammatory cells and vascular congestion than the sight that was not irrigated.

Pocket Depths, Clinical Attachment Levels and Inflammatory Markers (pockets between gum and tooth, levels of gum around tooth, gum redness/soreness molecular indicators): Impact of daily irrigation on the inflammation process is an important consideration. In a study, pro-inflammatory mediators in gingival crevicular fluid (GCF, in simple terms: gum pocket fluid) were examined at 14 days along with clinical findings, including Periodontal Pocket Depth (PPD). Irrigation with water adjunct to routine oral hygiene caused a significant reduction in PPD, bleeding on probing (BOP), gingival index (GI), and plaque index (PI), as well as a down modulation of pro-inflammatory mediators. In this study of mild-to-moderate periodontitis subjects, the PPD reduction was significantly better than the group which received only routine oral hygiene.

In another multi-center single blinded clinical trial, 155 participants (previously treated for periodontal disease under supportive periodontal maintenance therapy) were enrolled and followed up for 6 months. All subjects continued with their recommended oral hygiene routine. The group that added water irrigation demonstrated a significantly better reduction in gingival inflammation, BOP, and PPD.

Adverse events: Bacteremia is one of the most speculated adverse effect of water jet irrigations. Through certain cohort studies, it has been found that the incidence of bacteremia as reported in the literature is slightly lower ( 7% in gingivitis; 27 to 50% in periodontitis) than the incidence of bacteremia through routine oral hygiene practices [tooth brushing and flossing (20% to 68%), use of wooden toothpicks or sticks (20% to 40%), and mastication (7% to 51%)]

Patient QoL/Compliance: There are no direct studies on this subject yet, but it will be very helpful for us to evaluate these in future through patient’s perspective as well.

Final word:

Water flossing could be a helpful aid as an adjunct to routine oral health practices like brushing. It is slightly better than the string floss in reducing gingival bleeding scores. It is effective in reducing inflammation in the gingiva and is a 3 dimensional cleaning aid as compared to 2 dimensional cleaning offered by the floss.

Future implications for clinical practice would be to recommend water flossing with tooth brushing for maintenance. Future implications for clinical research would be to evaluate patient’s preferences and attitudes towards water jet irrigations. It would be interesting to know its performance on maintaining peri-implant tissues. Long cohorts with minimum confounders should be performed to make the better recommendations with including populations having other underlying genetic or acquired diseases or conditions which make it hard for them to take good care of their periodontal health (eg, diabetes, smoking, cancer, immunocompromised, mental disorders)


  1. Lainson PA, Bergquist JJ, Fraleigh CM. A longitudinal study of pulsating water pressure cleansing devices. J Periodontol. 1972;43(7):444-446.
  2. Cutler CW, Stanford TW, Abraham C, et al. Clinical benefits of oral irrigation for periodontitis are related to reduction of pro-inflammatory cytokine levels and plaque. J Clin Periodontol. 2000;27(2):134-143.
  3. Newman MG, Cattabriga M, Etienne D, et al. Effectiveness of adjunctive irrigation in early periodontitis: Multi-center evaluation. J Periodontol. 1994;65(3):224-229.
  4. Romans AR, App GR. Bacteremia, a result from oral irrigation in subjects with gingivitis. J Periodontol. 1971;42(12):757-760.
  5. Felix JE, Rosen S, App GR. Detection of bacteremia after the use of an oral irrigation device in subjects with periodontitis. J Periodontol. 1971;42(12):785-787.
  6. Lockhart PB, Brennan MT, Sasser HC, et al. Bacteremia associated with tooth brushing and dental extraction. Circulation. 2008:117(24):3118-3125.
  7. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754. doi: 10.1161/CIRCULATIONAHA.106.183095.
  8. Healthy Habits. (n.d.). Retrieved February 24, 2017, from
  9. Rosema NA, Hennequin-hoenderdos NL, Berchier CE, Slot DE, Lyle DM, Van der weijden GA. The effect of different interdental cleaning devices on gingival bleeding. J Int Acad Periodontol. 2011;13(1):2-10.